Provider Demographics
NPI:1083846562
Name:OPITZ, TODD
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:OPITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 CHANTICLEER
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-4809
Mailing Address - Country:US
Mailing Address - Phone:908-878-6509
Mailing Address - Fax:
Practice Address - Street 1:770 WOODLANE RD
Practice Address - Street 2:
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-3804
Practice Address - Country:US
Practice Address - Phone:609-267-5928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN276101164W00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No164W00000XNursing Service ProvidersLicensed Practical Nurse